1255428314 NPI number — PEDIATRIC PULMONOLOGY DEPARTMENT OF UNIVERSITY OF UTAH

Table of content: (NPI 1255428314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255428314 NPI number — PEDIATRIC PULMONOLOGY DEPARTMENT OF UNIVERSITY OF UTAH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC PULMONOLOGY DEPARTMENT OF UNIVERSITY OF UTAH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255428314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
295 CHIPETA WAY
Provider Second Line Business Mailing Address:
U OF U SOM DEPT OF PEDIATRICS
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84108-1220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-587-7400
Provider Business Mailing Address Fax Number:
801-587-7417

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N MEDICAL DR
Provider Second Line Business Practice Location Address:
PEDIATRIC PULMONOLOGY
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84113-1103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-588-2621
Provider Business Practice Location Address Fax Number:
801-588-2640
Provider Enumeration Date:
10/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CHAIR
Authorized Official Telephone Number:
801-587-7400

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0214X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 121229000 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100507112 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807149200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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